Find resources and forms you need to care for our members. If you have any questions about filling out and submitting online or paper forms, please contact Customer Service for assistance.
Forms and Tools
Member Benefit Grids
Member Benefit grids act as a reference guide and not a guarantee of coverage. If a service or treatment is not listed in the member benefit grid, refer to the appropriate prior authorization category for more information.2019 Benefit Grids
MA Value Plan 016
MA Plan 006
MA Pharmacy Plan 008
MA Pharmacy Plan 009
MA Extra Plan 010
- Browse 2019 Tier One Formulary
- Browse 2019 Tier Five Formulary
- Formulary Exception / Medicare Part D Coverage Determination Request Form
- Drug Recall Report
Pharmacy Billing Codes
Claims Billing and Coverage Determination
For pharmacy coverage determination, please call 1-800-417-8164.
You can submit a request for a coverage determination review by sending in a Coverage Determination Request form or filling out the online form.
Clinical Practice Guidelines for Chronic Medical Conditions and Preventive Services
Community Health Plan of Washington uses guidelines for the chronic diseases (including two behavioral health conditions) listed below. Reference is made to the pertinent evidence-based, peer-reviewed guidelines from nationally recognized agencies.
Guidelines are reviewed at a minimum of once every two years. The Clinical Quality Improvement Committee (CQIC), which includes Medical Directors and other practitioners, participate in this review and approve any changes. Paper copies of the guidelines themselves are available on request, as well as below at the link provided.
Utilization management is a process of reviewing whether care is medically necessary and appropriate for patients. Our process includes the use of prior authorization, concurrent review, and post-service review to ensure appropriateness, medical need, and efficiency of health care services, procedures, and the appropriate place of service.
Who does the review?
The review is done by the appropriate licensed staff, which includes — but is not limited to — nurses, medical director, and pharmacist. Community Health Plan of Washington staff is available to discuss any utilization management process, authorization, or denial.
Prior Authorization review is the process of reviewing certain medical, surgical, and behavioral health services. This is to ensure the medical necessity and appropriateness of care are met prior to services being delivered.
Approvals for Services
Community Health Plan of Washington staff and providers determine whether services are approved or denied. We use information from your doctor to do this. We also look at medical standards. Our decisions are fair and equal. We follow these rules:
- Utilization Management decision makers approve or deny based only on whether the care and service are appropriate and whether the care or service is covered.
- Community Health Plan of Washington does not reward providers or others for denying coverage or care.
- Community Health Plan of Washington does not offer financial incentives to encourage Utilization Management decision makers to make decisions that result in under-using care or services.
How We Evaluate New Technologies
Community Health Plan of Washington is committed to keeping up with new technologies. This means we review new tests, drugs, treatments, and devices and new ways to use current tests, drugs, treatments, and devices.
New technologies are evaluated on an ongoing basis. They are approved based on standards that protect patient safety.
We handle new technology requests for a specific member in a timely manner. They are processed as prior authorization requests. All requests are subject to current benefits and coverage limitations. Members denied a service or referral have the right to submit an appeal.
To learn more about the decision process or whether a specific new technology is covered by Community Health Plan of Washington, please call our Customer Service team at 1-800-440-1561 (TTY Relay: Dial 7-1-1), Monday through Friday, 8:00 a.m. to 5:00 p.m.
Appeal and Payment Dispute RightsAppeal Rights
Non-Contracted Provider: In accordance with the Medicare Managed Care guidance, non-contracted providers have appeal rights. Appeal rights apply to any claim CHPW has denied payment. Requests for payment appeals must include a completed and signed “Waiver of Liability” (WOL) statement. CHPW cannot begin the appeals process without a signed WOL. Requests for appeals that do not include a WOL will be dismissed. Requests for payment appeals must be filed within 60 calendar days of receiving the PRA. A copy of this PRA and supporting documentation must be submitted with the appeal request. CHPW must make a decision regarding the appeal within 60 calendar days from the date the appeal request is received.
If CHPW upholds the initial payment denial following review of the appeal or does not make a decision within 60 calendar days from the date the appeal request was received, CHPW will submit the appeal request to the IRE for review. The IRE will review the appeal and notify the provider in writing of the decision. If CHPW upholds the original claim denial, non-contracted providers have the right to ask the CMS contracted IRE to review the appeal.
Non-Contracted Providers: In accordance with Medicare Managed Care guidance, non-contracted providers have payment dispute rights. Payment dispute rights apply to any claim the provider contends the amount paid for a covered service is less than the amount that would have been paid by Original Medicare. Payment dispute rights apply to any claim there is a disagreement between the non-contracted provider and CHPW regarding the decision to pay for a different service than the billed service. Requests for payment disputes must be filed within 120 calendar days of the PRA. CHPW must make a decision regarding the payment dispute within 30 calendar days from the date the payment dispute is received.
Payment disputes are subject to CMS review as CHPW is required to pay non-contracted providers the same amount the provider would have received had the provider billed Original Medicare. The non-contracted provider payment dispute process can not be used to challenge payment denials that result in zero payment. Payment denials may be appealed as described in the Non-Contracted Provider Appeal section above.
Question about the non-contracted provider appeal or payment dispute process can be directed to our Customer Service department toll-free at 1-800-942-0247 (TTY 711), 7 days a week, from 8:00 a.m. to 8:00 p.m.
Please submit your Review and or Payment Dispute to:
Community Health Plan of Washington
Attn: Community HealthFirst Appeals & Grievances
1111 Third Avenue, Suite 400
Seattle, WA 98101
All of our providers must be compliant with state and federal regulations. For a full list of policies and to find more resources about Fraud, Waste, and Abuse, and Ownership and Control Disclosure, please refer to the Compliance Program page.
Policies and Procedures
Community Health Plan of Washington makes certain policies and procedures available to providers. If you need hard copies of any of our materials, contact your Provider Relations Representative. Current policies that you need to care for members can be found below.See all policies and procedures
Advance Directive Policy (CO291)
Authorization and Certification (UM203)
Delegated Vendor Oversight Policy (CO321)
Emergency Fill Policy (PM516)
Exclusion Screening Policy (CO318)
Extension of Benefit Limitations (UM428)
Filing Forms B, C, and D with the Office of the Insurance Commissioner (OIC) (CO362)
Hospice Care, Pediatric Concurrent Care, and Pediatric Palliative Care Policy (MM163)
Hospital Admission Patient Management (UM211)
Injectable Medications Policy (PM566)
Involuntary Disenrollment Policy (EM111)
Medicare Opioid Overutilization Program Policy (PM564)
Patient Review and Coordination Program Policy (PM563)
Pharmaceutical Management Procedures Policy (PM508)
Pharmaceutical Patient Safety Policy (PM509)
Pharmacy Access During a Federal Disaster or Other Public Health Emergency Declaration Policy (PM514)
Pharmacy Review of Coverage Redeterminations (PM555)
PCP Assignment (CS437)
PCP Assignments for State Programs (EL150)
Prescription Claim Processing for Part D Policy (PM558)
Prohibition on Enrollee Charges for Covered Services (PR153)
Provider Data for Directories (PD104)
Quantity Limits Policy (PM506)
Reporting Requirements for Medicare Part D Policy (PM561)
Security Incident Response Policy (CO370)
Step Therapy Policy (PM507)
Transition Process Policy – MA (PM553)